Tennis Elbow (Lateral Epicondylitis)

Tendons are cords of living tissue that connect muscles to bone. They act as the cables that allow joints to move at a distance from muscular contraction. This gives a mechanical advantage. Tennis elbow is a painful condition affecting the tendons that attach the muscles of the back of the forearm to the arm. These muscles act when gripping in the power grip position. Tennis elbow arises not just from serving at tennis or using too large a grip on your tennis racquet. It can be caused by any repeated twisting movements of the hand and wrist for example when using a screwdriver. It is common in patients who have manual occupations. Tennis elbow is also known as lateral epicondylitis to doctors. The condition most commonly occurs in people aged between 35 and 55. It is most common in males with a manual occupation. It is most common in the right hand.

WHAT CAUSES IT?

Predisposing factors to the tendon damage and healing inflammation that results are rarely a single injury such as a blow to the arm and more commonly overuse. Overuse causes microscopic tears in the tendon. Causes include swimming, gardening, throwing sports and golf. Also, manual occupations that involve repetitive turning or lifting the wrist, such as plumbing bricklaying, using scissors or shears cause it. In attempt to heal the tear inflammation occurs and it is this inflammation that is the cause of the pain. Rupture of the tendon paradoxically results in an earlier cure.

HOW IS IT DIAGNOSED?

There is a clear history of pain first thing in the morning getting better with exercise. The pain is intermittent at first but may become continuous and affect sleep. There may be tenderness over the broad origin of the forearm muscles on the outside of the elbow. If you have severe elbow pain, can't move the joint or have any loss of feeling, you should seek medical treatment urgently. This may be due to infection of the joint rather than tennis elbow.

You will not usually be required to undergo X-rays, but they may be recommended to rule out other conditions, such as arthritis, that can cause elbow pain. If there is doubt to the diagnosis then your doctor will suggest an MRI scan. This gives an image of the soft tissues, including muscles and tendons, rather than the bones.

HOW IS IT TREATED?

Most people with mild symptoms of tennis elbow can try conservative treatments like RICE (rest, ice, compression and elevation). In the acute phase an arm wrap like the Donjoy “Surround” provides both the compression and the cold therapy if it is kept in the fridge overnight.

Try pain killers, non-steroidal anti-inflammatory drugs like ibuprofen. Physiotherapy has been shown to be as effective as a local anaesthetic and cortisone injection or an arm wrap. Your GP may refer you to a sports medicine doctor or a physiotherapist. For a tennis elbow that is persistently painful a doctor may suggest a steroid injection.

Physiotherapy should include exercises, ultrasound treatment, heat treatment, using an infra-red lamp and help to design a rehabilitation programme.

Most pain will go without any more than the treatments described within a year.

WHAT ABOUT SURGERY?

Surgical treatment is reserved for those who have severe pain, persistent symptoms after medical treatment, or who are at risk of permanent loss of occupation. The aim is to release the tendon at the elbow. A temporary tourniquet is used to make the operative field free of blood. If you are medically fit, have someone who can collect you and look after you over night after the operation, the operation can be done on a day case basis. However, if you have other medical problems such as diabetes, asthma or high blood pressure, you may have to stay overnight after surgery.

WILL I HAVE TO HAVE A GENERAL ANAESTHETIC?

The operation can be done under sedation and local anaesthetic (asleep). Your anaesthetist will advise you about the best choice of anaesthetic for you. In addition, local anaesthetic may be injected into your elbow while you are asleep to reduce the pain after the operation even if you go to sleep for the surgery. You will also be given pain-killing tablets to take home.

WILL I HAVE A PLASTER AFTER?

No, you will not have a plaster on. However, you may need to buy a Clinical Shoulder Immobiliser to wear for one or two weeks after surgery.

WHAT HAPPENS AFTER SURGERY?

You can go home when comfortable. For the first 72 hours, you should rest with your elbow elevated to reduce swelling. Keep the dressings dry with a “Limbo” if necessary. You will be seen in the clinic 2 weeks after your operation. The dressings will be removed, the wound examined and the stitches removed. You may be prescribed physiotherapy. Another clinic appointment will be made for 4-6 weeks later.

WHAT ARE THE RISKS?

Elbows always swell up after surgery and can become stiff. Swelling is part of your body's natural response to any injury and surgery is no exception. People vary in how stiff they are after an operation. Elevation of the limb will help. You can afford to move the elbow early with the exercises given by the physiotherapist.

The wounds usually heal quickly, but occasionally these can become infected and need early suture removal and antibiotics once your doctor has taken a swab to identify the bacterium.

HOW SOON CAN I?

Go back to work?

This depends on what you do and how you get to work. If you have a sitting-down job and you can get to work, you could probably go back to work 1-2 weeks after surgery. On the other hand, if you have a heavy manual job you may be off for up to 6 weeks. If you need to drive to work, this will affect when you can go back. Your surgeon will advise you about going back to work.

Play sport?

Before your dressings have been removed you can start gently exercising your elbow. Everyone is different in how quickly they can take up exercise again. Most people can get back to most of their previous activities within 3 months of tennis elbow release.